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MUST BE COMPLETED BY THE TESTER IN INK Des Moines Water Works 2201 Valley Dr. Des Moines IA 50321 Phone 283-8775 Fax 283-8723 Attn. John Lins Distribution Department BACKFLOW DEVICE TEST REPORT Customer or Business Name Contact Person Phone Number Mailing Address Service Address Isolation Containment Device Protects Backflow from Date of Test Time Type of Assembly Manufacturer Height off Floor A.

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